A Randomized Placebo-controlled Trial of Adjunctive D-cycloserine in Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder
Overview
- Phase
- Phase 2
- Intervention
- D-cycloserine
- Conditions
- Major Depressive Disorder
- Sponsor
- University of Calgary
- Enrollment
- 50
- Locations
- 1
- Primary Endpoint
- Montgomery-Asberg Depression Rating Scale (MADRS)
- Status
- Completed
- Last Updated
- 4 years ago
Overview
Brief Summary
Transcranial magnetic stimulation (rTMS) is an approved treatment for depression. The purpose of this study is to test an adjunctive medication, D-cycloserine, in rTMS for depression using a placebo-controlled design. D-Cycloserine is a partial N-Methyl-D-Aspartate receptor (NMDAr) agonist, and therefore may enhance the effects of rTMS, however there is data to support and refute this hypothesis. Using a double-blind design, the investigators will randomize patients with Major Depressive Disorder to receive either daily low dose D-cycloserine or placebo in conjunction with rTMS to the left dorsolateral prefrontal cortex. After 10 treatments (2 weeks), this double-blind period will conclude and all participants will receive an additional 10 treatments (2 weeks) of rTMS without any adjuncts. The primary outcome will be improvement in clinician rated depressive symptoms at the conclusion of the study.
Detailed Description
Major Depressive Disorder (MDD) is a common and debilitating illness. For an unacceptable proportion of patients, depressive symptoms remain impairing despite multiple treatments. Increasingly, non-invasive brain stimulation techniques are being explored as a means of targeting specific brain regions and networks that are implicated in depression. Repetitive transcranial magnetic stimulation (rTMS) is the non-invasive stimulation technique with the largest evidence base in MDD. Targeting the dorsolateral prefrontal cortex (DLPFC) with rTMS has proven an effective treatment for MDD, however as many as 2/3 of patients will not experience substantial improvement. Adjunctive agents are a potential strategy to improve patient outcomes. The objective of the proposed study is to determine the efficacy of adjunctive D-cycloserine with rTMS directed to the left dorsolateral prefrontal cortex (DLPFC) in acute Major Depressive Episodes. The investigators propose to utilize a stimulation protocol called the intermittent theta-burst protocol to study rTMS in conjunction with D-cyloserine using a randomized double-blind, placebo-controlled design with allocation concealment. Patients with Major Depressive Disorder will be randomized to receive 1) rTMS+cycloserine, or 2) rTMS+placebo in a 1:1 ratio for two weeks (10 sessions). At the conclusion of the 2-week blinded augmentation phase, patients will continue to receive two weeks of rTMS without an augmentation agent or placebo. The primary outcome measures will be improvement in depression as measured by change in Montgomery Asberg Depression Rating Scale (MADRS). In addition, the investigators will also be looking at the improvement of other clinical outcome measures, quality of life and changes in brain functional dynamics, as assessed with functional Magnetic Resonance Imaging (MRI), and metabolites, as assessed by Magnetic Resonance (MR) Spectroscopy.
Investigators
Eligibility Criteria
Inclusion Criteria
- •are competent to consent to treatment
- •have a Mini-International Neuropsychiatric Interview (MINI) confirmed diagnosis of DSM-5 criteria Major Depressive Disorder with a current episode of at least moderate severity of depression, single or recurrent
- •have failed to achieve a clinical response to one adequate trial of antidepressant medication within the current episode, or been unable to tolerate antidepressant medications.
- •have a score ≥ 18 on the Hamilton Depression Rating Scale 17-item
- •have a Young Mania Rating Scale Score of ≤ 8
- •have had no change in dose, or initiation of any psychotropic medication in the 4 weeks prior to randomization
- •are able to adhere to the treatment schedule
- •pass the TMS adult safety screening (TASS) questionnaire
Exclusion Criteria
- •Allergy to Cycloserine
- •Have failed adequate trials of ≥4 antidepressant treatments in the current episode.
- •have an alcohol or substance use disorder within the last 3 months
- •have suicidal ideation (score of 4 ≥ on item 10 of MADRS)
- •are at a significant risk of harm to themselves or others
- •history of psychosis
- •are currently pregnant , breast feeding or plan to become pregnant
- •have a lifetime Mini-International Neuropsychiatric Interview (MINI) diagnosis of other primary psychiatric diagnoses as assessed by a study investigator to be primary and causing greater impairment than Major Depressive Disorder.
- •have failed a course of electroconvulsive therapy (ECT) in the current episode. Previous ECT treatment outside of the current episode does not influence inclusion.
- •history of non-response to rTMS treatment.
Arms & Interventions
D-Cycloserine
Participants will orally ingest a capsule containing 100mg of the antibiotic d-cycloserine daily (Monday-Friday) for the first 2 weeks of rTMS treatment (10 sessions), followed by 2 weeks of rTMS without adjunctive medication.
Intervention: D-cycloserine
D-Cycloserine
Participants will orally ingest a capsule containing 100mg of the antibiotic d-cycloserine daily (Monday-Friday) for the first 2 weeks of rTMS treatment (10 sessions), followed by 2 weeks of rTMS without adjunctive medication.
Intervention: Transcranial Magnetic Stimulator
Placebo
Participants will orally ingest a capsule identical to that containing the study medication, however this capsule will contain a placebo. They will ingest this capsule daily (Monday-Friday) for the first 2 weeks of rTMS treatment (10 sessions), followed by 2 weeks of rTMS without adjunctive medication.
Intervention: Transcranial Magnetic Stimulator
Placebo
Participants will orally ingest a capsule identical to that containing the study medication, however this capsule will contain a placebo. They will ingest this capsule daily (Monday-Friday) for the first 2 weeks of rTMS treatment (10 sessions), followed by 2 weeks of rTMS without adjunctive medication.
Intervention: Placebo oral capsule
Outcomes
Primary Outcomes
Montgomery-Asberg Depression Rating Scale (MADRS)
Time Frame: Administered at baseline, at the halfway point (week 2), and after rTMS treatment (week 4)
Change in severity of depressive symptoms as measured by the MADRS, a clinician-rated instrument. The MADRS is a ten-item diagnostic questionnaire used to measure the severity of depressive episodes. The overall score ranges from 0 - 60. Cutoff points are 0-6 = normal, 7-9 = mild depression, 20-34 = moderate depression, \>34 = severe depression.
Secondary Outcomes
- Clinical Response(Administered at baseline, at the halfway point (week 2), and after rTMS treatment (week 4))
- Anhedonia(Administered at baseline and after rTMS treatment (week 4))
- Cognitive Function(Administered at baseline and at the halfway point (week 2))
- Personality Measures- BFI(Administered at baseline and after rTMS treatment (week 4))
- Functional Magnetic Resonance Imaging (fMRI)(Administered at baseline and week 2. Change in cycloserine group vs change in placebo group)
- Clinical Remission(Administered at baseline, at the halfway point (week 2), and after rTMS treatment (week 4))
- Quality of Life as measured by the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire(Administered at baseline, week 1, at the halfway point (week 2), week 3, and after rTMS treatment (week 4))
- Anxiety Symptoms(Administered at baseline, week 1, at the halfway point (week 2), week 3, and after rTMS treatment (week 4))
- Workplace Productivity(Administered at baseline, week 1, at the halfway point (week 2), week 3, and after rTMS treatment (week 4))
- Functional Disability(Administered at baseline, week 1, at the halfway point (week 2), week 3, and after rTMS treatment (week 4))
- Self-reported Cognition(Administered at baseline, week 1, at the halfway point (week 2), week 3, and after rTMS treatment (week 4))
- Magnetic Resonance (MR) spectroscopy(Administered at baseline and week 2. Change in cycloserine group vs change in placebo group)
- Clinical Global Impression(Administered at baseline, at the halfway point (week 2), and after rTMS treatment (week 4))
- Implicit Suicidal Thoughts(Administered at baseline and at the halfway point (week 2))
- Personality Measures- DEQ(Administered at baseline and after rTMS treatment (week 4))
- VAS for General Health(Administered at baseline, at the halfway point (week 2), and after rTMS treatment (week 4))
- Perception of Illness(Administered at baseline and after rTMS treatment (week 4))
- Depressive Symptoms(Administered at baseline, week 1, at the halfway point (week 2), week 3, and after rTMS treatment (week 4))